SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE

The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor 3) The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action? Assess the client's readiness to learn. 4) A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action? Monitor respiratory status. 5) The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used. 1) Place the client in a semi Fowler's position. 2) Turn on the suction device and set the regulator at 80 mm Hg. 3) Attach the suction tubing to the suction catheter. 4) Hyperoxygenate the client. 5) Insert the catheter into the tracheostomy until resistance is met, and then NURSING Med Surg 2SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE . SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE . pull it back 1 cm. NURSING Med Surg 2SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE . SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE . 6) Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth. 6) The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority? Remove the IV catheter. 7) A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed. All options must be used. 1) Close the roller clamp on the IV tubing. 2) Spike the IV bag and half-fill the drip chamber. 3) Open the roller clamp and fill the tubing. 4) Uncap the distal end of the tubing. 5) Attach the distal end of the tubing to the client. 8) The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 9) The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? The client with problems clearing the airway related to abdominal incision pain 10) The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child NURSING Med Surg 2SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE . SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE . has a patent airway. Which action is the next priority in the care of this child? Prepare the child for a chest radiograph. NURSING Med Surg 2SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE . SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE . 11) The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made? "Actual or life-threatening concerns are the priority." 12) A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used. 1) Check the client's blood glucose level. 2) Give the client ½ cup (118 mL) of fruit juice to drink. 3) Take the client's vital signs. 4) Retest the blood glucose level. 5) Give the client a small snack of carbohydrate and protein. 6) Document the client's complaints, actions taken, and outcome. 13) An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first? A 45-year-old man with chest pain, shortness of breath, and diaphoresis 14) The nurse is assigned to care for 4 clients. Which client should the nurse assess first? A client who has a peripheral (index finger) oxygen saturation percentage of 85% 15) The nurse has received her client assignment for the day. Which client should the nurse care for first? NURSING Med Surg 2SAUNDERS COMPREHENS